A standardized process for conducting the preparticipation physical examination is needed to ensure a safe playing environment for athletes and to help identify
those conditions that may predispose an athlete to injury or sudden death, says the National Athletic Trainers' Association in a new position statement.

While PPEs - or what used to be called sports physicals - are required as a condition for participation in school sports and are routinely used to identify conditions that put athletes at risk, there has been continued debate as to their effectiveness.

In addition, "the different organizations charged with developing and revising the PPE - from state high school associations to medical associations, state health and education departments to legislators - often have different missions," says Kevin Conley, PhD, ATC, associate professor and director of Athletic Training Education at the University of Pittsburgh and lead author of the statement, "which can lead to confusion."

The issuance by the NATA of a position statement advocating for adoption of its PPE form, however, could have precisely the opposite effect, to the extent it competes with a PPE form developed by six national medical societies in 2010 (PPE Monograph), which at least those medical societies are advocating as the standard towards which the nation should move.

A 2014 survey (Madsen NL, 2014), for instance, found that only 23 states mandate a single statewide form, and only 8 use a form that is consistent with the PPE Monograph, meaning that only 11% of US high school athletes are guaranteed to receive a PPE that is fully consistent with what the medical societies view as a national standard.

Because the PPE represents the sole source of medical evaluation for 30 percent to 88 percent of children and adolescents annually, Conley said the NATA is recommending "a standardized PPE process to determine risk factors and ascertain that athletes are physically and mentally prepared for sports participation."

Based on current and scientific evidence and best practices, the NATA has developed the following PPE guidelines designed for physicians, athletic trainers, and other health care professionals to apply, regardless of the sport or an athlete's performance goals, designed to identify conditions that may threaten the health and safety of participants in organized sports or require further evaluation and intervention, or even disqualification.

Medical and Family History: "Cornerstone" of PPE

A comprehensive medical and family history should be obtained from each participant and remains the cornerstone of the PPE. Research suggests that such a history identifies 75 percent of problems that affect initial athletic participation.

The history should:

take into account the areas of greatest concern for sports participation, particularly the American Heart Association's recommendations for preparticipation cardiovascular screening of competitive athletes;

be reviewed carefully, and both the athletes and parents should be questioned and reconfirm their responses.

pay particular attention to musculoskeletal injuries, often common causes for restriction or disqualification, as well as prior surgeries or related underlying conditions that might predispose an athlete to injury.

Physical Examinations recommended

A general physical examination is recommended and should include a check of vital signs (e.g. height, weight and blood pressure; visual acuity, cardiovascular/pulmonary, abdominal, neurologic and general medical and musculoskeletal examinations). Although another provider may record the initial vital signs for efficiency, the data should always be reviewed by the physician. Further examination should be based on potential concerns uncovered during the history.

Cardiovascular screening for risk factors

Specific questions regarding risk factors and symptoms of a cardiovascular disease should be asked during the history portion of the PPE (see box below). As noted earlier, a positive response to any question should be confirmed and further evaluation conducted if necessary.

Auscultation - or listening to - the heart should be performed initially with the patient in both standing and supine positions and during squat-to-stand motions to clarify any type of murmur.

Although echocardiography (ECG) is not considered a routine part of a PPE screening, the results may have benefits in some cases. ECGs and stress tests remain the most commonly recommended diagnostic tests for patients with an abnormal cardiovascular history or exam.

Questions Regarding Presence of Cardiovascular Risk

Have you ever passed out during or after exercise?

Have you ever been dizzy during or after exercise?

Have you ever had chest pain during or after exercise?

Did you get tired more quickly than your friends do during exercise?

Have you ever had racing of your heart or skipped heartbeats?

Have you ever been told that you have high blood pressure or high chloresterol?

Have you ever been told that you have a heart murmur?

Has any family member or relative died of heart problems or of sudden death before age 50?

Have you had a severe viral infection (for example, myocarditis or mononucleosis) within the last month?

Has a physician ever denied or restricted your participation in sports for any heart problem?

Neurologic screening

A thorough neurologic screening is necessary if the athlete has a history of concussions, seizure disorder, cervical spine stenosis or spinal cord injury.

The athlete should be evaluated for full range of neck motion. Symptoms such as weakness, paresthesia (e.g. tingling, tickling, prickling, pricking, or burning of a person's skin) or numbness in the arms, hands or legs should prompt further testing.

Individuals playing sports that are associated with a high risk of concussions may be considered for baseline neuropsychological testing during the PPE. Although there is no magic number of concussions that disqualifies an athlete from further participation in contact sports, the NATA says that athletes with a history of three or more concussions or delayed recovery may need to be considered for temporary or permanent disqualification from contact sports.